Medicare Noncoverage Notices

Transcription

1 March 2014

2 This job aid is intended to assist home health and hospice clinicians in: Understanding and complying with regulations for issuing required Medicare notices at the time of termination and change of care. Describing the process for notifying patients of their rights to an expedited review determination. Overview of Termination and Change of Care Notices The Medicare Conditions of Participation for both home health and hospice and Section 1879 of the Social Security Act require that patients be notified prior to the termination of covered services and before a patient may be held liable for payment. In addition, home health agencies are required to notify patients prior to the reduction of services that were not specified within the initial plan of care. The forms used to make these notifications include the: Advance Beneficiary Notice of Noncoverage (ABN) (CMS-R-131) Notice of Medicare Noncoverage (NOMNC) (CMS 10123) Detail Explanation of Noncoverage (DENC) (CMS-10124) Home Health Change of Care Notice (HHCCN) (CMS-10280) Purpose of Noncoverage and Change of Care Notices The ABN and NOMNC give patients the option to request an immediate coverage decision by Medicare before being held liable for charges. The HHCCN gives patients the opportunity to obtain additional care from other providers. 2 of 12

3 Notice Specifics Notice Issued By: Issued To: Issued When Advance Beneficiary Notice of Noncoverage (ABN) (CMS R 131) Notice of Medicare Noncoverage (NOMNC) (CMS 10123) Detailed Explanation of Noncoverage (DENC) (CMS 10124) Home Health Change of Care Notice (HHCCN) (CMS 10280) Home Health and Hospice agencies Home Health and Hospice agencies Home Health and Hospice agencies Home Health agencies ONLY Medicare Fee For Service (FFS) patients receiving Medicare Part A and Part B services Not issued to patients under a Medicare Advantage (MA) Program Medicare Fee For Service (FFS) patients receiving Medicare Part A and Part B services Medicare Advantage (MA) Program patients. Medicare Fee For Service (FFS) patients receiving Medicare Part A and Part B services Medicare Advantage (MA) Program patients. Medicare Fee For Service (FFS) patients receiving Medicare Part A and Part B services Not issued to patients under a Medicare Advantage (MA) Program. Prior to the delivery of what the agency believes to be Medicare noncovered services. With each new year of providing Medicare noncovered services. At least two days prior to the end of ALL Medicare covered services. A patient requests an expedited review after being issued the Notice of Medicare Noncoverage. Medicare covered services are: Reduced outside of the original plan of care. Terminated while other covered services continue. Terminated for agencyspecific reasons (i.e., staffing issues, unsafe environment, failure to obtain Face to Face encounter). 3 of 12

4 Examples of When the ABN Would be Issued: In home health, the ABN is commonly issued in the following situations: When services are no longer covered due to Medicare coverage guidelines. Examples include: patients who are no longer homebound, patients who no longer have a medically reasonable and necessary need for home health services, or patients who have met all treatment goals. When supplies or services are ordered or requested that are not part of the Medicare home health benefit. Examples include custodial care, telehealth and many medications. In hospice, the ABN is commonly issued in the following situations: If services are noncovered for reasons other than those listed, or if the services are not part of the home health or hospice benefit, then the ABN is not required to be issued. When patients are discharged because they no longer have a terminal condition but they wish to continue to receive hospice services. Services and items are not reasonable and necessary for the palliation or management of the terminal illness. When supplies or equipment are ordered or requested that are not part of the Medicare hospice benefit. When specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary to the patient's condition. When the level of hospice care is not appropriate to the patient s condition. 4 of 12

5 Triggering Events for Issuing the ABN Include: Initiation of services An ABN is required when an agency expects that an item or service will not be reimbursed by the Medicare home health or hospice benefit. The notice is required to be issued before the noncovered care is delivered. Reduction of services An ABN is required when services are reduced if the beneficiary elects to continue to receive care that is no longer considered medically reasonable and necessary. Reduction in the level of care An ABN is required when a hospice reduces the level of care if the beneficiary elects to continue to receive the higher level of care. Termination of services An ABN is required when an agency ends delivery of all Medicare-covered care, while other non-covered care continues. With each new year For ongoing, continuous noncovered care exceeding a year in duration, another ABN must be issued as each new year begins, assuming coverage remains unchanged. Additional noncovered care started If during the course of treatment, additional noncovered items or services are needed, the agency must issue the beneficiary another ABN describing these services. 5 of 12

6 Important Points When Issuing the ABN The ABN must be issued by employees or subcontractors of the home health or hospice provider who understand the requirements and can clearly respond to any questions the patient may have. The ABN must be verbally reviewed with the patient and any questions raised during that review must be answered before the form is signed by the patient. The patient may designate a representative to act on his or her behalf to review and sign the ABN. All methods of delivery of the ABN must adhere to HIPAA privacy standards. The ABN must be delivered far enough in advance that the patient or representative has time to consider the options and make an informed choice before the services are stopped. ABNs are never required in emergency or urgent care situations. The ABN applies only to items and services furnished by the home health or hospice agency, and not for those obtained from other sources. Other providers may be required to issue their own ABN. The ABN should be delivered in-person and prior to the delivery of medical care that is presumed to be noncovered. If in-person delivery is not possible, the ABN may be issued to the patient via telephone, by mail, via a secure fax, or via a secure . 6 of 12

7 Completing the ABN When completing the ABN, the form requires that for Option D, a label be entered for the item or service that is believed to no longer be covered by Medicare. Medicare recommends the following Option D labels: Item Service Laboratory test Test Procedure Care Equipment Since Medicare largely reimburses for the services provided in home health and hospice, Service will be the most common label for this field. Agency Liability If it s discovered by a Medicare Contractor that an agency did not properly deliver an ABN prior to the delivery of noncovered care, or that the ABN was incomplete, the agency would be held liable for payment of the noncovered items and services. An agency will also likely have financial liability for items or services if it knows, or should have known, that Medicare would not pay for the items or services and it fails to issue an ABN when required. 7 of 12

8 Issuing the Home Health Change of Care Notice The Home Health Change of Care Notice (HHCCN) is only issued by home health agencies and not hospice agencies. It is used to notify beneficiaries of services that are being reduced or terminated due to physician orders or limitations in the agency s ability to provide specific services. The form is given for changes that occur outside of the original plan of care. Examples of When the HHCCN is Issued: Prior to the agency reducing or discontinuing Medicare-covered care listed on the plan of care because of a physician-ordered change in the plan of care or a lack of orders to continue care (Option Box 1). Prior to the agency reducing or discontinuing care listed on the plan of care for agency-specific administrative reasons (Option Box 2). Care termination because of failure of the patient to meet required Face-to-Face Encounter requirements (Option Box 2). Issuing the HHCCN in these situations does not impact financial liability. It serves as a written change of care notice that is required by the home health Conditions of Participation. 8 of 12

9 Issuing the Notice of Medicare Noncoverage (NOMNC) The Notice of Medicare Noncoverage (NOMNC) is issued by home health and hospice agencies at least two calendar days prior to the anticipated date that ALL Medicare-covered services will end. After receiving the NOMNC, if the patient does not agree with the discharge decision, he or she may request an expedited review from a Quality Improvement Organization (QIO) contractor. If an expedited review is requested by the patient, the agency must then complete and issue a Detailed Explanation of Noncoverage (CMS-10124) (DENC) to the patient. This form gives a greater explanation as to why coverage is ending. A copy must be given to the patient and sent to the QIO by the close of business on the day of the patient s request. Issuing the Notice of Medicare Noncoverage (NOMNC) The triggering event for issuing the NOMNC is termination by the last discipline. Examples of when the NOMNC is issued include: Patients who are no longer homebound Patients who have achieved home care goals and no longer require services Patients whose services have been discontinued by the physician. When the patient is no longer diagnosed as having a terminal condition. 9 of 12

10 Examples of When a Noncoverage or Change in Care Notice Would NOT be Required Patients who are discharged to the same or a higher level of care do not require discharge notices to be issued. Examples include transfers to other agencies, patients discharged to a hospital or skilled nursing facility, and home health patients who are transferred to hospice services. Patient refuses services or revokes the hospice benefit. Patient moves out of the agency s service area. The agency changes the brand of supplies. There is a change in caregiver. There is a change in visit days, although the ordered frequency is met. In hospice, the patient dies and the family will receive bereavement services. A single evaluation visit is made but skilled or hospice services are not implemented. 10 of 12

11 General Noncoverage and Change of Care Form Guidelines The following general guidelines apply to the ABN, HHCCN and the NOMNC: The forms may be legibly handwritten or typed. If typed, a serif or sans serif font should be used with a size of 12 points or greater. Abbreviations should not be used unless they are defined within the form. The top of each form may be customized to include the agency s name, logo and contact information. No other customizations may be allowed. If printed, the ABN and HHCCN should be only one printed page, although the forms may be printed in letter or legal size to accommodate the agency s identifying information. The NOMNC must remain only two pages. It may be two sides of one page or one side of two separate pages. When entering patient identification numbers, in no situations should the patient s social security or Medicare number be used. Each form may be delivered to the patient electronically and signed by the patient or representative digitally; however, a hard copy of the form should still be provided to the patient at the time of signature. The patient may request to sign a hard copy version of the form. 11 of 12

12 Assistive devices or assistance by others may be used to sign and date the form. If assistance is required, an annotation should be included explaining the reason and assistance provided. If the patient refuses to sign the form, the provider should annotate the notice to that effect, and indicate the date of refusal on the notice. The date of refusal is considered to be the date of notice receipt. Beneficiaries who refuse to sign either form continue to be entitled to the contents of the form. Each form may be delivered to a beneficiary s appointed or authorized representative. Appointed representatives are individuals designated by beneficiaries to act on their behalf during the signature or appeal process. In most situations, notification to a patient who has been deemed legally incompetent should be made to the legally authorized representative of the beneficiary (e.g., legal guardian, durable power of attorney, etc.). If it is not possible to deliver a notice personally to a patient, the patient or representative may be notified via telephone of the contents of the notice within the timeframe required for notice delivery. The two copies of the notice should then be mailed to the patient or representative for signature, with a stamped selfaddressed envelope provided for return delivery of one of the signed notices. If both the provider and the representative agree, agencies may send the notice by fax or , though they must ensure that all HIPAA privacy guidelines are followed. 12 of 12